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GH 5036
GH 5036 is the room number of the General Hospital LAC+USC Medical Center (Los Angeles, California) Neurosurgical Intensive Care Unit This manual is a compilation of practice guidelines for house and attending and nursing staff that may also be useful for education of medical students and neurosurgical patients. There is no intention to recommend or endorse any of the therapies or interventions mentioned herein for any actual neurosurgical patient.
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Physiologic manifestations of disease of the central nervous system seen (and managed) in 5036 include: Cerebral edema, Vasospasm, Diabetes insipidus, Syndrome of inappropriate antidiuretic hormone.
increased intracranial pressure (ICP)
Physiologic manifestations of disease of the central nervous system seen (and managed) in 5036 include: Cerebral edema, Vasospasm, Diabetes insipidus, Syndrome of inappropriate antidiuretic hormone.
increased intracranial pressure (ICP)
Procedures for pre- and post-op monitoring and/or therapy (done at the bedside as well as in the OR).
The most common diagnoses of patients admitted to 5036 include:
brain tumor, pituitary tumor, and subarachnoid hemorrhage
Both hydrocephalus and brain tumors are associated with ICP management problems -- hydrocephalus is treated in the ICU with placement of a ventricular catheter, brain tumors with diuresis (forced urination) and intravenous steroids.
After pituitary surgery patients frequently have problems with excessive urination causing them to become dehydrated. The excessive urination of diabetes insipidus is accompanied by a higher than normal blood salt content (hypernatremia) that can make patients mentally altered or even comatose.
Subarachnoid hemorrhage patients who survive the first few minutes after the bleeding are likely to end up in the Neurosurgical ICU where they are evaluated for cerebrovascular pathology and, depending on the pathology identified, prepared for neurosurgical intervention (open craniotomy, embolization, etc.)
A number of devices for therapy and monitoring are used in 5036.
Devices are placed to monitor physiologic responses to disease and therapy.
Many of the devices used for monitoring and treatment require a tube in a body or brain cavity. (e.g. Swan-Ganz catheter in pulmonary artery, (ventricular catheter in brain). Insertion of these catheters or tubes usually requires a puncture through skin but may also require penetration of bone and sometimes even the dura mater and cortical surface of the brain..
Some risks, such as infection, are common to all catheters placed through the skin into body cavities, but some are specific to the location at which they are placed and the body cavity that they enter.
Neurosurgical critical care Emergencies are clinical situations that can rapidly lead to death and require immediate intervention to avert irreversible neurologic injury and/or death.
Fever -
Hypoxia -
For the most commonly encountered pathophysiologic problems and treatments there are standard management protocols in the Neurosurgical ICU. These algorithms, protocols, guidelines, standards. as well as ndications, contraindications, quantities/doses, complications, and precautions are specific to 5036 but derived from the neurosurgical literature and standard neurosurgical texts (see Bibliography)
Steroids -
Drug coma - Incisional bleeding
A number of medico-legal issues frequently arise in caring for patients in 5036.
Harvesting organs from patients who are brain dead has been possible only in the past 25 years with improvements in life support, transportation, communication.
Informed consent is required for all invasive procedures done on patients able to understand and agree.
Victims and perpetrators of crime being treated in the Neurosurgical ICU have legal rights.
Considerations of privacy.
Life support, Do Not Resuscitate orders, Brain death, Discontinuation -- Donation. Transplantation. Comfort. Dignity.
Immigrants are likely to have relatives, frequently their only "family", back in their country of origin. The families of patients in critical condition in 5036 frequently require documentation of medical status/treatment/prognosis prior to considering a request for a emergency family visitation from across the border.
Power of attorney / Advance directive
A large number of legal and ethical issues associated particularly with permanent coma and death.
Decisions related to ethical issues:
Life support Initiation/Discontinuation/Withdrawal
Do Not Resuscitate orders
Organ donation
copyright 2004 JPGruen MD
